Psych Mental Health Nursing // ATI Remediation

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. the client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing?

"You're saying that you think you are fat and using laxatives because you're afraid of gaining weight" -uses therapeutic technique of summarizing to review the key points of the discussion

A nurse is preparing to discharge an older adult client who attempted suicide to his home where he lives alone and has difficulty performing ADLs. Which of the following referrals should the nurse initiate?

1. Occupational therapy 2. Meal delivery services 3. Home health services 4. Physical therapy

A nurse in a mental health unit observes a client who has acute mania hit another client. Which of the following actions should the nurse take first?

Call for a team of staff members to help with the situation -the greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance and to prevent further injury to himself or others

A nurse is reviewing routine lab values for several clients who are taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity?

A client who has a sodium level of 128 mEq/L -this low sodium level indicates the client is at risk for lithium toxicity b/c renal excretion of lithium is decreased in the presence of a low sodium level

A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement?

Ask group members to discuss their feelings about this client's monopolizing behavior. -this intervention will validate other members' feelings toward the client who is dominating the meeting. It also should encourage group problem solving

During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The client reports that a bomb was placed in her room by a family member during visiting hours. Which of the following actions should the nurse take?

Assess the client for evidence of a perceptual disturbance. The nurse should assess the situation to determine if the client is hallucinating or misperceiving external stimuli (experiencing illusions)

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium?

Easily distracted -hallmark of delirium

A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care?

Encourage the client to drink 125 mL of fluid each hour while awake.

A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect?

Greater risk of attempting suicide as affect and energy improve An initial response to amitriptyline can develop in 1 week. For a client who has been severely depressed with suicidal ideation, the energy to carry out a plan is more possible after 1 week of treatment.

A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?

Mild -this is when the client will be able to concentrate and process information

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following OTC meds that the client reports taking should alert the nurse to a potential adverse reaction?

Phenylephrine -otc med for sinus congestion, colds, allergies -affect the sympathetic nervous system Can cause severe hypertension if taken with a MAOI antidepressant

A nurse is planning care for a preschool-age child who has ADHD. Which of the following interventions should the nurse identify as the priority?

Remove unnecessary equipment from the child's surroundings. Greatest risk to a child who has ADHD is injury from impulsive behavior and the decreased ability to perceive self-harm.

A nurse is caring for a client who has schizophrenia and was prescribed a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2mg IM?

Shuffling gait -used to treat bc this is a manifestation of parkinsonism

A nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization?

Temp 35.6°C (96.1°F) Severe hypothermia is a temp lower than 36°C (96.8°F) due to loss of subcutaneous tissue or dehydration, requires hospitalization

A nurse is providing teaching to a client who is to begin undergoing light therapy at home to treat seasonal affective disorder. Which of the following should the nurse include in the teaching?

Wear sunglasses when outdoors -light therapy, or phototherapy, can cause eye strain and sensitivity to light